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MAIN LINE AFFILIATES

Clinical Neuropsychologist

Radnor, Pennsylvania

Provider NPI: 1083777239

Organization Information:
Organization Name:  MAIN LINE AFFILIATES
Organization is not Subpart
Authorized Official:  MICHAEL J BUONGIORNO  EXEC. VP & CFO  484-3378481

Practice Location:
1 RADNOR CORPORATE CTR SUITE 400 RADNOR, PA 19087 US
Tel: 610-254-1450  Fax: --

Business Mailing Address:
950 E HAVERFORD RD SUITE 110 BRYN MAWR, PA 19010 US
Tel: 610-526-8480  Fax: --

Entity Type: Organization

Taxonomy:

PrimaryCodeCategory/DescriptionStateLicense Number
N103G00000XBehavioral Health & Social Service Providers
Clinical Neuropsychologist
N103T00000XBehavioral Health & Social Service Providers
Psychologist
N261QR0405XAmbulatory Health Care Facilities
Clinic/Center
PA237078
N261QR0405XAmbulatory Health Care Facilities
Clinic/Center
PA151081
N103TC0700XBehavioral Health & Social Service Providers
Psychologist
N103TR0400XBehavioral Health & Social Service Providers
Psychologist
N101YA0400XBehavioral Health & Social Service Providers
Counselor
N2084P0802XPhysicians
Psychiatry & Neurology
N2084P0804XPhysicians
Psychiatry & Neurology
N261QM0850XAmbulatory Health Care Facilities
Clinic/Center
Y2084P0800XPhysicians
Psychiatry & Neurology

Other Provider Identifiers:

IssuerNumberStateType
UNITED - CAD ADULT IOP10182401
MAGELLAN - CAD DREXEL HIL28011000001
AETNA HMO - CAD DREX HILL298383001
MAGELLAN - CAD EXTON23120000001
IBC - BMR PSYCH ASSOC066470400001
1007726370011PA05
CIGNA - CAD DREXEL HILL208983401
IBC - MLA231741900001
AETNA HMO - BMR PSYCH047000901
UNITED - CAD ADOLESCENT10182501
VALUEOPTIONS - MLA29319501
MAGELLAN - MLA47144300001
AETNA PPO - MLA798519701
UNITED - CAD - ADULT PHP10182301
CIGNA - CAD EXTON208983501
AETNA HMO - CAD EXTON298391001
Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin







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